Provider Demographics
NPI:1609102862
Name:WAKEFIELD, BRENDA (LMT)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:WAKEFIELD
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10225 MARCHANT LN
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-4503
Mailing Address - Country:US
Mailing Address - Phone:937-620-4286
Mailing Address - Fax:
Practice Address - Street 1:665 W LBJ FWY
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75063-3712
Practice Address - Country:US
Practice Address - Phone:214-380-9700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-22
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT110561225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist